04-JUL-C-3
BEGIN OUR
HAITIAN HALF OF THE MEDICAL MISSION,
AWAKENING IN
“DELVA’S HOTEL” IN THUMONDE,
AS THE
STRESSED OUT TEAM REGROUPS FOR THE CLINICS IN MARMONTE—THE CLINIC ALL REHABBED
AND READY,
FOR THE BWUMC
TEAM TO SEE A WIDE VARIETY AND LARGE NUMBER OF PATIENTS ON OUR FIRST FULL
PROJECT MEDISHARE DAY
July 26, 2004
I have returned in the Project MediShare Toyota Land Cruiser with a group of the Haitian daughters of our Guest House host Delva as he and several of his drivers are down in Port au Prince with my AmEx Gold Card and MD driver’s license trying to rent the other two SUV’s they could not get yesterday since there was no one in the rental agency being Sunday, and no on e they could roust out to find the other two we had been assured would have picked us up last night before I had negotiated for the big bus that got us here to Thumonde after midnight.
We got up, early for me and considerably later for the others, as I took a walk out into the landscaped area around the new and very fancy Guest House that former Thumonde major Delva had built on his mothers’ property to keep the only real guests that they got on any kind of regular visit basis—the Project MediShare volunteers—a captive audience for the accommodation. It is really quite splendid, and even has a computer access for Internet by direct satellite dish—a device that works, despite the absence of any phone lines, only, of course, when the generator is fueled and cranked up as it is at present to allow me to type in these lines.
Both Del, last night, and Marie Cherie this morning, were extremely embarrassed that this mix-up, for which they took full responsibility, had so inconvenienced us. If the day we spent yesterday was a waste with all of us waiting for a group of SUV’s to transfer us which never arrived within eight hours of when they were supposed to have arrived and when they did come in they were hardly adequate to carry even our baggage let alone our twenty people, they were glad we had taken the initiative to get the bus and come on over to Thumonde even if it did mean arriving by night over some of the world’s most horrendous roads now lined with semi-conscious Haitians still “celebrating” the World Cup match in which their team (why Haitians identified with Brazil over Argentina I do not know) won and might have walked off their inebriation until they lay down in the roadway, the way that South Africans do on Easter weekend. If there would be a traffic fatality, I was not going to have it be one of our people getting involved in the legal issues of who was at fault for extinguishing, rather than enhancing, any life in Haiti, so that a professional and very skilled bus driver did it well was worth the heavy price he tried to extract from me. Since Del had coughed up the US cash to cover the bus, he had no money to pay for the extra rental SUV’s today, which explains why he is down in the capital today with my driver’s license and credit card. There will probably be some reimbursement for paying for all these not necessarily delivered services not just overcharged once, but twice. But, meanwhile, we had an introduction session with the personnel here and Marie Cherie and a student named Loren who is trying to get data on a maternal and child health thesis for a PhD in Anthropology from the University of Florida where A F Burns is Anthropology Chairman and my host at last Springs’ Global Health Day at which I was Keynote Speaker. One of the other former students of the group that included Parker Small of Pediatric Pathology and Rosenblum of Pediatrics is Serge Geffraud, who had joined us for the last day of DR and first day of Haiti, to be the only other doctor in the group as a cardiology pediatrics fellow. I will send back greetings through that group through each of the two UF former students.
DELVA’S
“CELINE GUEST HOUSE”=
19* 01.12 N,
AND 71* 58.15 W
Marie runs the Project MediShare, partner of Zanmi La Sante or (in English) “Partners in Health” based out of the Brigham in Boston and now involving clinics in Russia, Peru and elsewhere, at one of which Paul Farmer is just now. We will try to rendezvous later in the week, when we will be at Cange Hospital if and when he returns there. I am a busy boy today, covering four teams of general medical and a special pediatric clinic at the Marmonte Clinic which I now “own” as a gift to me on behalf of the GWUMC from the Minister of health, with whom we will meet late tomorrow. As it turns out, the vacant Marmonte Health Center we visited last year had been rehabilitated with Marie Cherie on deck, and the large number of drugs we had brought are also filled in by the stock that they had kept from prior missions, and our drug stores will be pushed in “behind” their drug stock so that most of the prescriptions we wrote today will be from this stock replenished by our own, since our expiration dates are much fresher than theirs
As we arrived at the clinic, the usual crowds of people were awaiting, and they looked very dignified as they sat in their very Sunday best, elegantly perched atop a burro sidesaddle or delivered across the deep washouts in a pickup truck. The crowd parted as I carried in the last of my MAP packs which we will empty out here along with much of the surgical gear to be left at Cange Hospital. As I walked through the crowd, they parted showing me their upturned faces under their straw hats and murmuring a response to my “Bon Jour.” We had about 150 lined up at arrival and another half that number came in while we were in progress. The system now includes an LPN in the triage and both pharmacists and assistant pharmacist so we do not have to spend any time translating the instruction sin how to take the medicines, which will all be done by Creole speakers. Marie Cherie, a Haitian American oversees this whole operation, as I shuttled from room to room making spot diagnoses or doing consultations. There were scores of interesting patients, a number of them with serious and significant problems. We will go through that list when we review the patient presentation later tonight, a separate list for Haiti here, rather than the prior list of the interesting patients of the Dominican Republic. The team was both exhilarated and exhausted upon return and felt like the experience had been kicked up a level. The presentations will tell whether they assimilated the intensive medical education from last week’s work through yesterday. I had a thorough work-out in chasing around with only one team headed by Serge doing what I did not have to review for every patient, and even then I was called to consult on several of his patients. The pharmacy operations moved more surely as we had the Creole native speakers doing the interpretations. So, it was a good full half day, and now I am awaiting the afternoon rainy season squall to cool it off even if just a little.
PATIENT
PRESENTATIONS AND GOOD DISCUSSION
BACK AT
DELVA’S “CELINE GUEST HOUSE”
FROM THE
EXPERIENCE IN MINE AND GWU’S OWN CLINIC—
MARMONTE,
GIVEN TO ME LAST YEAR BY THE HEALTH MINISTER OF HAITI’S CENTRAL PLATEAU
A-1 Neely: A 24-year-old man with a non- itching and non inflammatory rash of raised blood vessels on his forearms and legs, with a short period of weight loss. I took one glance and showed him to the others, none of whom came up with the instant diagnosis—Kaposi’s Sarcoma. I explained the VCT regimen, Voluntary Counseling and Testing as I knew it from Malawi, and they have a version of it here that is less formalized. I sent him for the HIV test which will take some time since it has to be followed in the protocol of the VCT.
B-1 Siayavash: a tender mass in a woman’s midline intragluteal cleft: this is a rapid diagnosis as well—she has a pilonidal cyst. Bryan Schaaf had got medically evacuated from Haiti for the treatment of the same lesion. We advised her to come by the dispensaire.
C-1 Anthony: a 70-year-old woman with headache, weight loss, RUQ pain and cachexia; I had only glanced for an instant and had asked Anthony, “What does she have besides TB?”
D-1 Anisha: a child with a heart murmur that was to be differentiated, and by a maneuver Serge, pediatric cardiology fellow, determined that it was a venous hum.
A-2 Mike: a 62-year-old man with epigastric pain radiating through to his back a little bit of jaundice, weight loss and occasional fatty stools; here is a chance t use the portable ultrasound machine, since I suspect that he has very little chance of a good news bad disease—pancreatitis or a pseudocyst—but a big chance for a bad disease for which there is no treatment—in Haiti or in DC—pancreatic cancer.
B-2 Laurie: a 35-year-old with dizziness and vertigo; here we get the differential of neurologic and auditory diagnoses, after ruling out hypertension and inflammatory disease; it seemed to be related to the inner ear, and a sedative antihistamine was given
C-2 Sonbol: twin brothers with the same affliction as well as identical appearances; they both had both ringworm and tinea capitis of the scalp
D-2 Lindsay: an 18-month-old with unaccountable swelling in the liver—hepatomegaly without a palpable spleen; it was non-tender, so it may have represented some type of storage disease, but that would also involve the spleen as well as the whole reticuloendothelial system,. We agreed with the hepatomegaly in an asymptomatic kid which is simpy called a finding.
As a special concession to the Public health Students who may have felt left out on a number of the esoteric medical discussions, a third round was held with an emphasis on public health projects.
A-3 Bryan: a fellow who had had a VCT, and a Haitian doctor refused to tell him of his positive result; the Haitians are the number two recipient of the Global Health Fund’s money for HIV treatment, with 62 million dollars over five years, as PIH had shown the example; but such refusal to acknowledge may keep any program from working.
B-3 Adam: a question of childhood nutrition; a five year old girl had not really made the transition to foods after being weaned, and when the “Mother’s Club” was suggested, the mother had never heard of such an alleged social support system in operation.
C-3 Duc: a 20-year-old man with three year’s penile discharge; the question is about reportable diseases and treatment of partners for this which is obviously the GC clap; but if he had ulcerative or gummatous venereal disease, that transmits not only the organism but also gives a higher chance for HIV transmission. We treated him with Penicillin and tetracycline, and advised a VCT.
D-4 Martha: a 62-year-old woman with hypertension is found and started on RX; how can she be followed in an area without doctors to see that she stays on meds and is monitored? Since there seemed to be no long-term care potential she was at least put on low-dose aspirin.
It seemed that the separate round of public health questions was a bit contrived and did not have the immediate answers of many of the clinical cases, so that it is my impression that the public health should best be integrated into the clinical medicine. As I had said, the credibility of any prevention measures rests entirely on the willingness to treat; no one can turn their nose up at someone sick, alleging that we are only here to prevent disease not treat it. But, those who treat must work a public health approach into every interaction, in a culturally appropriate mode. It is fortunate that at the getgo, they have some one with the clinical, tropical medicine, public health and anthropology credentials to lead this kind of integration; it would not work at all if it were fragmented and the credibility of curative medicine did not underscore the efforts in public health.